Needless to say, it would be upsetting if you were given the wrong medication because a nurse confused you with another patient. Furthermore, what if a surgeon performed a procedure on you that was meant for another patient? These types of errors are the reason health care providers check your wristband and ask for you to confirm your identity before you receive a test or treatment. But are these steps adequate to prevent patient identification errors? Unfortunately, maybe not. How common are these errors and what can hospitals and patients do to reduce their occurrence?
How do patient identification errors occur?
Every time a health care staff member interacts with a patient, from the reception desk to the operating room and everywhere in between, each staff member must properly identify the patient. Additionally, anytime a health care professional uses either an electronic or paper-based system to record or access information about a patient, it’s critical that he/she properly identifies the patient. Of course, health care professionals are people and they make mistakes like the rest of us, leading to errors in the patient identification process. For example, providers working simultaneously with multiple records can easily enter information about a patient in another patient’s record. Or a provider can confuse patients and give a patient the wrong medication. Because this process is repeated continuously in hospitals all over the world, there is a huge potential for wrong-patient errors.
How often does this happen?
It’s hard to say! Since patient identifications errors can elude detection, it’s very difficult to correctly estimate how frequently these errors occur. However, in a survey for the 2016 National Patient Misidentification Report, 64% of 503 US healthcare executives claimed that patient identification errors happen more frequently than the reported industry standard of 8-10%. Furthermore, the report states that, on average, a hospital loses $17.4 million/year in denied insurance claims associated with misidentification.
How do patient identification errors harm patients?
Patients may get the wrong medication, test, surgery, or treatment. Conversely, patients may not receive a needed medication, test, surgery, or treatment, causing their conditions to worsen. The consequences of patient identification errors can be minor billing mistakes or devastating medical errors resulting in serious harm or death.
Here are some examples of patient identification errors that occurred in last 5 years:
A blood labeling error leads to a deadly transfusion.
At Baylor St. Luke’s Medical Center in Houston, a tube of blood from a prior ER patient was sent to the lab when the next patient, a 75-year-old woman, needed a transfusion. Sadly, the lab staff didn’t realize the blood in the tube didn’t belong to the current patient, leading to the patient receiving the wrong blood. The erroneous transfusion led to repeated episodes of cardiac arrest causing the patient’s death the next day. Unfortunately, this labeling error was not the first error of its kind at this hospital. An internal hospital committee identified problems with the way staff labeled blood samples a year before this incident, but no improvements in the process were made. In fact, regulators identified 122 incidents over 4 months in which the staff made blood labeling errors.
A patient receives chemotherapy meant for a different patient with the same name.
As a patient checked in for chemotherapy treatment, the clerk asked the patient to confirm the information on his wristband. Although the patient confirmed his identification, he did not notice that the information was for a patient with the same name, but a different birth date. Next, in the infusion area, he again confirmed that his wristband had the correct information. Due to these patient identification errors, the patient received chemotherapy meant for the other patient with the same name, but different birth date. Although minimal harm was done, the patient sued the hospital and won.
Patient dies after receiving medication meant for another patient.
At Australia’s Macquarie University Hospital, 54-year-old Paul Lau died 6 hours after routine knee surgery when he received medication meant for another patient. Following Lau’s surgery, while the anaesthetist (an MD) operated on another patient, he reopened Lau’s electronic record to prescribe fluids through his IV line. Unfortunately, the doctor didn’t close Lau’s record and mistakenly ordered the opioid fentanyl for Lau that he meant to order for his current patient. Tragically, the doctor overrode 22 alerts triggered by the electronic record system. Although the pharmacy and/or nurses could have intervened and prevented this deadly medication error, it was ultimately the anaesthetist’s mistake.
Near-miss when 2 patients share name and birth date.
In the UK, 60-year-old David Edwards went to the hospital by ambulance after experiencing chest pains. He provided his personal details upon arriving in the emergency department, where they treated and released him the same day. The following week, picking up medication prescribed at the hospital, he noticed some incorrect personal details. It turns out there are two David Edwards, with the same birth date, who use the same hospital. Although there was no harm done, there could have been serious consequences as he was treated according to another patient’s records. Certainly, it’s possible he could have been harmed if any tests or treatments were ordered that did not align with his actual health profile.
Are there rules and regulations to prevent patient identification errors?
Currently, there are no federal laws regulating how providers identify patients. But, well-respected organizations provide guidelines to prevent these kinds of errors, including those listed below. Certainly, these recommendations are helpful but don’t prevent all patient identification errors. Therefore, patients must actively participate in the identification process.
The Joint Commission’s first National Patient Safety Goal addresses how to improve the accuracy of patient identification. Their recommendations for steps providers should take to support accurate patient identification include:
- Using an active confirmation process to help match the patient and documentation.
- Using a standardized process for patient identification and capturing patient information, no matter where registration occurs.
- Clearly displaying information required to accurately identify the patient on electronic displays, wristband and printouts.
- Implementing monitoring systems to readily detect identification errors.
- Using alerts and notifications to facilitate proper identification, such as warning users when they try to create a record for a new patient (or look up a patient) whose first and last names are the same as those of another patient.
Additionally, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society collaborated to develop safety standards for chemotherapy administration to reduce the risk of error. Their ongoing collaboration updates their guidelines for practitioners that outline steps to avoid medical errors, including patient identification errors.
What steps do hospitals take to reduce patient identification errors?
- Checking at least 2 patient identifiers—usually, name and date of birth, although some providers use a medical record number or another identifier.
- Checking bar-coded identification information on a patient’s wristband against information on a medication label or the patient’s medical record.
- Using biometric patient identification, such as retinal scanning or fingerprint confirmation.
Lisa Schulmeister, an oncology nurse, recommends additional steps that could prevent patient identification errors:
- Staff should ask the patients for their name and birth date, instead of asking the patient to confirm what they hear.
- Electronic records systems should only allow 1 patient record to be open at a time.
- Staff should only print and use labels with patient information one patient at a time. Batch labeling can result in staff applying the wrong label to a blood vial or medication, including chemotherapy.
- Test result reviews should include verification of patient identity information to avoid staff entering results into the wrong patient’s record.
- Staff should verify patient identification upon every encounter that requires confirmation, not just at the onset of care delivery that day – even in facilities where nurses and doctors feel they “know” their patients.
Why doesn’t the US have national patient identifier numbers?
A 2008 RAND Corporation report states that providing a unique patient identifier number for each patient would reduce the risk of patient identification errors. And, it would minimize the risk of providers placing information in the wrong medical records. Furthermore, it would simplify interoperability, increase patient confidence, and protect patient privacy. Importantly, the report estimates it could save $77 billion/year.
So, why doesn’t the US have a national identifier system? In a 2016 STAT article, author John McQuaid explains that the US is far from adopting this solution due to many factors, including privacy and security concerns, political resistance and the widespread use of electronic health records that can’t communicate with each other. Yet, other countries use national patient identifiers, including the United Kingdom and Australia.
Of course, a unique patient identifier is not going to solve all problems associated with mixing up patients. For example, overwhelmed medical staff may still confuse two patients with the same last name. And stressed staff may give the wrong treatment or test to a patient. However, it seems likely that the number of patient identifier errors would significantly decrease.
How can you protect yourself?
Firstly, never assume the provider has properly identified you. Even if they address you by your name, that doesn’t guarantee they are referencing your medical records or giving you medications or treatments meant for you. I suggest the following:
- Always make sure the medical staff knows who you are (by matching name, date of birth or other identifiers) and is following medical orders for you, not for another patient. And check not only when you first arrive – but at every step of your journey. For in-patient settings, be sure staff checks the patient ID bracelet regularly.
- It might seem radical but ask your provider (or hospital) if they have any other patients with your name. If so, take extra precautions at every step in your medical journey to make sure you are correctly identified.
- If something doesn’t seem right, speak up immediately! Don’t take medications, or agree to treatments, that are unfamiliar or unexpected. Importantly, don’t worry about appearing foolish or annoying. Better safe than sorry.
- You have the right to look at your medical records, and you should. Read them over to make sure the information is accurate. Tell the doctor and/or nurse if you see something that isn’t right.
- If the patient is unable to advocate for him/herself, a trusted family member of friend can stay with the patient to ensure that doctors and nurses always properly identify him/her.
- Take detailed notes at all doctors’ appointments and while in the hospital. Keep organized records of all medical tests, procedures, and medications with the patient at all times. This will help if there is missing or incorrect information in your medical records.
- Check your medical bills carefully before paying them to be sure each bill is for the correct appointment or procedure.
In order to further reduce your risk of harm from a hospital stay, read these posts:
- Is Your Hospital Safe? Are Programs in Place to Avoid Dangerous “Never Events”?
- What’s Your Hospital’s Safety Record? Is Your Hospital Safe?
- Protect Yourself from Hospital Infections.
- Why is Hand Washing in Healthcare So Important? What You Need to Do to Stay Safe.
- The Benefits of Participating in Hospital Rounds.
- How to Avoid Medication Errors in the Hospital and at Home.
- Tips for Hospital Discharges.
- What’s a Frequent Cause of Hospital Readmissions? Miscommunication.